Take Home Message: Completing
a sport-specific movement control exercise program 3 times per week reduced
musculoskeletal and concussion injuries in school-age rugby athletes.

Injury prevention warm-up programs decrease the risk of injury in sports
such as basketball and soccer. However, little is known about whether these
programs prevent injuries in rugby, which is a sport with a lot of player
contact and a high risk of concussion and musculoskeletal injuries. Therefore,
the authors conducted a cluster-randomized trial to determine if a movement
control exercise program could prevent musculoskeletal injuries and concussions
among school-age rugby players. They also sought to assess the effect of
different doses (via compliance/adherence) on injury risk. All of the invited
schools had onsite nurses and physiotherapists who would treat rugby-related
injuries. The authors randomized 40 independent schools (participating in
either under-15, 16, or 18 rugby teams) to either a movement control program or
a basic exercise program. Both programs were comprised of 4 progressive phases,
which would be performed during the first 20 minutes of each pitch-based
training session and match warm-up. The coaches attended a 1-hour pre-study
workshop on how and when to implement the programs. Seventeen schools completed
the movement control program (44 teams, 1,325 players), which integrated
balance/perturbation training, resistance training, plyometric training, and
controlled rehearsal of sports-specific landing and cutting maneuvers with
verbal feedback and reinforcement of technique from the coach. Fourteen schools
(39 teams, 1,127 players) completed the basic exercise program, which consisted
of running-based warm up, dynamic stretching, controlled wrestling, mobility
and speed of direction drills (without coach feedback). The authors counted an
injury if it resulted in a time loss of > 24 hours. The school medical staff
recorded each injury location and diagnosis. Coaches reported the length of
each training session, number of players attending each session, information
about the matches played, and the number and level of each program phase the
athletes completed each week. Overall, there were no differences between
interventions; however, a closer look shows that athletes who performed the movement
control program may be 28 to 34% less at risk for head/neck, upper extremity, or
concussion injuries compared with the athletes in the control program.
Additionally, the authors found that athletes who performed the movement
control program at least 3 times per week suffered 72% fewer injuries and 59% fewer
concussions compared with those who performed the basic exercise program more than
3 times a week.

The
authors demonstrated that a movement control, sport-specific excise protocol
that is implemented at least 3 times per week may alter the amount of injuries
high school rugby athletes sustain. It is important to note that there was
likely a dose effect, which highlights that a good injury prevention program
will only be effective if the coaches and athletes commit to performing the
program as prescribed. Only 12 out of 63 teams performed the programs 3 or more
times/week on average. One issue may be the duration of the program. The
recently released Consensus Opinion for Best Practice Features of Injury Prevention Programs advocated that
programs should only take 10 to 15 minutes to promote compliance. The 20-minute
warm-up program may be too long, which led to a low compliance rate. These
findings also support the consensus opinion’s recommendation that injury
prevention programs should be performed at least 2 to 3 times/week. This study
offers strong evidence that an injury prevention program can reduce the risk of
injury in rugby but there is a need to find approaches to promote compliance.
Currently, medical professionals should be aware of these prevention programs.
They should also try to implement a shorter version of this program or ensure
compliance with the current program to help reduce the risk of injury among rugby
players.

Question for
Discussion: Are you currently using any preventative warm up protocols? If not,
would you consider implementing them? If so, which sports in particular would
you focus on?

6
comments:

Dan Rosenblum
said...

Thank for the summary Dr. McDevitt.

I think it's really interesting that this study focused exclusively on rugby athletes, because most of the injury prevention program studies that are out now focus on sports like soccer and basketball.

I did a bunch of research on the FIFA 11+ Injury prevention program while I was an undergraduate. My research focused mainly on the compliance with the program based on the athlete's sex, level of play (JV vs. Varsity), and effect that the "coaching environment" has on compliance with the program. Basically what we were finding was that the coaches had a major influence on the completion rates of the program. One of the most common complaints was that it took too long (supposed to take 20 minutes). We also were finding that coaches with more experience were less likely to complete the program. Aside from that, just talking to the high school athletes, a large majority did not like doing the program, despite the previous literature that proves its injury prevention effects that are almost up to almost 80% in some cases.

As a clinician, I dont understand why coaches and athletes dislike these programs so much. They literally stop injuries from happening. I hope that one day we can convince coaches and athletes (maybe not the top level athletes because they are already highly motivated) that these programs are extremely beneficial. I will definitely incorporate the use of an injury prevention program into my clinical practice and I hope that other clinicians will too.

Thank you so much for sharing your experiences working with the FIFA 11+ program. I was wondering how long it actually took, because it says that there are 4 different levels, so I was wondering if as you progressed if it really did only take 20 minutes. I also wonder if it is the coaches that need to learn, demonstrate, and utilize the program if they just dont udnerstand some of the exercises and benifits. For example during rehab during an ankle sprain none of the athletes think it is important to scrunch a towel up or write the abc's while in the whirl pool, but you talk to them about why this is necessary and they are more apt to do it. I agree I think a simple follow up survey study on those that used the FIFA 11+ what did they like, not like so it could be tweaked and education on the reasoning behind the FIFA 11+ could be delivered better.

Thank you so much for the article. Rugby is a wild sport were anything can happen in the case of injuries. At some point there is no preventing some of them, but I love the idea of preventing as many as possible. I think that this prevention program was well designed, covering many different skills and methods. To lower possible head and neck injuries by 28-34% is very impressive and a positive sign for the future of preventative programs. A shorter program would be a great idea for athletes who struggle with compliance and coaches who may think of a long program as a “waste of time.” I have worked with many teams that implement a prevention program. I especially like programs that are created for an individual athlete. A main sport I saw this with was soccer, and the benefits definitely outweigh the time spent.

Allison, I agree with you. There is no way that we can prevent all sports injuries especially in a sport like rugby. However, I think there is enough evidence to start implementing these prevention programs. I am happy to hear that many teams are successfully implementing these programs. I feel if we can try and make it out to some coaching conventions and really teach them about the programs and tighten up the programs to fit into the individual sport and warm up time constraints it will be worth the extra 10-15 minutes of warm up time in the end when they have healthy athletes! I do also like your idea of the individual programs. I think with the different injury risk screens we have we could at least be identifying the most at risk athletes and provide them with these extra warm up exercises they should be doing to decrease their risk.

I think the results of the study are very interesting when it comes to the high percentage of decreased injury and concussion in rugby players. If the 20-minute warm-up session is able to protect players from injury, coaches should understand and want to incorporate it into practice without hesitation. However, this is oftentimes not the case and as mentioned in the summary, it is necessary to come up with strategies to promote compliance and support of the warm-up session. It was mentioned that injury prevention warm-up programs decrease the risk of injury in basketball and soccer, and the results show that it decreases the risk in rugby as well. Since football is fairly similar to rugby in some ways, I wonder how helpful the warm-up session would be in football and how much it decreases the risk of concussions or other injuries.

Sarah, That is a great question. I feel it would be beneficial to football players to perform a preventative warm up. However, because football is such a multifaceted sport much like any other sport programs, several different programs will probably have to be developed. However, I agree with your second comment I do think it could help alleviate other injuries as well such as upper extremity and concussions. There has been several research reports that revealed strong neck strength and good reaction time was helpful in decreasing concussion risk and worse concussion outcomes.

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